After about 15 years in different health care settings, Brad Tuttle and his wife, Alley Tuttle, decided to leave traditional health care and start a direct primary care clinic in Bangor because they saw a “big collapse coming.”

And now, with U.S. House Republicans moving forward with a vote on legislation that would cut nearly $1 trillion in spending on Medicaid over the next decade, Tuttle said the system is at further risk of “erosion.”

“What’s coming is very alarming,” Brad said. “We’re teetering on the edge already right now and if you come in and take $800 billion from Medicaid (as was initially proposed), we’re in serious trouble.”

Brad said direct primary care clinics like the one he and Alley opened in Bangor earlier this week are better positioned to endure cuts to Medicaid because they do not work with insurance, instead they bill patients directly. 

Apotheosis Health is one of a growing number of direct primary care clinics across the state. There are currently at least 30, more than half of which have opened in the last five years, according to DPC Nation (although a long-time Maine provider said this is likely an undercount).

Before opening their clinic, the Tuttles were both working in oncology and grew frustrated by insurance companies issuing denials, requiring treatment lines that weren’t preferable and dictating which medicine they could use. It got to the point where it felt like doctors had to just sign off on whatever the insurance company demanded, Brad said.

“It’s wild how this has kind of slipped,” Brad said. “It’s one of those slow declines … but when you really look at how things are changing, it’s scary.”

The couple wanted to find a way to make more of a difference for their patients, and decided primary care was the best place to start. Primary care is the first line of defense for health care, but it’s also been struggling with recruitment. There is a projected shortfall of about 87,000 primary care physicians nationally by 2037, according to a report from the National Center for Health Workforce Analysis.

Maine hospitals have been struggling with recruitment and financial issues for years. This week, Northern Light Health announced expected staffing cuts, although details were vague. Northern Light Inland Hospital closed in May, a California-based nonprofit announced plans to take over three hospitals through its purchase of Central Maine Healthcare, Mount Desert Island Hospital announced it would close its birthing unit in July and two Aroostook County hospitals said they would merge their management for a year to “remain viable.”

The major difference between hospital-based and direct primary care, Brad said, is how many patients providers take on. Apotheosis Health caps their practice at 500 patients (they have about 50 so far). A primary care provider at a hospital could have between 1,000 and 2,500, he said. (MaineHealth confirmed that its primary care providers typically have about 1,500 patients.)

The model of direct primary care harkens back to the 1950s, when family doctors were able to spend more time with patients and be much more available, Brad said. In-take appointments can be 90 minutes and annual visits can be an hour or more, if a patient would like. The couple are also available by call or text 24/7 via a HIPAA compliant phone app, Alley said.

They charge $90 a month for individuals, with discounts for couples and families. The payment covers unlimited visits, including an annual physical, annual labs, free or discounted antibiotics as well as any necessary follow-up visits.

While doing away with insurance and replacing a fee-for-service model with periodic payments may be attractive for providers and patients, it is also difficult to scale and tricky to implement for more specialized care. Premiums for malpractice insurance can run into the tens of thousands of dollars per year (for certain specialties in some counties in the U.S. insurance premiums can top $200,000), and the number of patients clinics take is limited by design. 

Steven Michaud, president of the Maine Hospital Association, said direct primary care is a good option as part of the larger health care mix but “that said, it doesn’t do much for those that can’t afford it.”

This is a misconception, according to Dr. Jack Forbush, one of the first in Maine to provide direct primary care. Of the 1,200 patients at his Hampden clinic, Forbush said about 95 percent are blue collar workers, and 80 percent don’t have any health insurance (like the Tuttles, Dr. Forbush recommends patients have some kind of catastrophic insurance for large emergencies).

It’s different from concierge medicine, which he said is commonly conflated with direct primary care but is a different model where the provider may still accept insurance, including government insurance such as Medicare and Medicaid, and charge a copay for visits. Fees at concierge clinics are typically higher, and they may offer a broader range of services. 

When Dr. Forbush converted his private practice to direct primary care in 2013, he said he was “flooded” with people who couldn’t get access to primary care. His patients, said Dr. Forbush, are drawn to the clinic because they say it’s accessible, affordable and provides continuity of care.

Dr. Forbush said he has heard criticism from peers that clinics like his contribute to the physician shortage by not taking on enough patients. He pushes back on that, saying the current system burns out physicians in a handful of years, whereas by taking on fewer patients, providers stay in the field far longer.

The Apotheosis Health facility run by the Tuttles also has a walk-in urgent care clinic and an infusion clinic, both open to anyone. Urgent care visits cost $150 and fluids cost $100. The goal, Brad said, is to help reduce emergency room visits by improving preventative care and offering relief through the urgent care clinic.

With 11.8 million Americans expected to lose Medicaid coverage under the Congressional bill, Brad said more Mainers will likely end up in the emergency room for basic care. Maine already has among the fifth-highest rate of emergency department visits in the country, due to its rural geography and limited access to primary care doctors

Nearly 400,000 Mainers are covered by MaineCare, the state’s version of Medicaid. The Maine Department of Health and Human Services has estimated that 31,000 people could lose their insurance and four rural hospitals could close in the first year alone, according to an interview Gov. Janet Mills gave to NPR this week. 

“As people start to lose coverage, the emergency department is really like a basket that catches everything,” he said. “If you don’t have insurance, a primary care visit to St. Joe’s or Northern Light is going to be pretty pricey and at some point people are just going to go to the emergency rooms.”

This story was originally published by The Maine Monitor, a nonprofit civic news organization. To get regular coverage from The Monitor, sign up for a free Monitor newsletter here.